基于Wichens认知模型降低住院药房调配门内差错的多中心研究
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摘要
目的:依据Wichens信息加工模型对摆药单和药品标签进行优化并进行多中心研究。方法:利用Wichens信息加工模型设计差错登记表,分析调配差错的发生机制。据此对摆药单和药品标签进行优化,并分别在A、B,C、D 4家医院实施,比较优化前后的调配差错数据。结果:A、B、C、D 4家医院优化后各类差错率和总差错率均较优化前明显下降(P <0. 05)。结论:Wichens信息加工模型有助于分析调配差错的发生机制,据此对标签和摆药单的优化设计可降低调配差错。
Objective: To optimize the prescription list and drug label according to the Wichens' information processing model,and investigate the effectiveness and feasibility of the multi-center study. Methods: The error registration form was designed and the mechanism of dispensing errors was analyzed by the Wichens' information processing model. The prescription list and drug label were optimized and implemented in four hospitals respectively marked A,B,C and D. The rate of dispensing error before and after the optimization was compared. Results: After the optimization,the error rate and the total error rate of all the four hospitals were significantly decreased when compared with those before the optimization (P < 0. 05). Conclusion: The Wichens' information processing model is helpful to analyze the mechanism of dispensing errors. The optimal design of labels and dispensing lists can reduce the information processing errors resulting in the reduction of dispensing errors.
Objective: To optimize the prescription list and drug label according to the Wichens' information processing model,and investigate the effectiveness and feasibility of the multi-center study. Methods: The error registration form was designed and the mechanism of dispensing errors was analyzed by the Wichens' information processing model. The prescription list and drug label were optimized and implemented in four hospitals respectively marked A,B,C and D. The rate of dispensing error before and after the optimization was compared. Results: After the optimization,the error rate and the total error rate of all the four hospitals were significantly decreased when compared with those before the optimization (P < 0. 05). Conclusion: The Wichens' information processing model is helpful to analyze the mechanism of dispensing errors. The optimal design of labels and dispensing lists can reduce the information processing errors resulting in the reduction of dispensing errors.
引文
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9中国药学会医院专业委员会.推荐的四个药品管理标示[EB/OL].(2012-05-04)[2018-02-20]http://www.cpahp.org.cn/ccyyf/news/201205/1446.htm
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2 Anacleto TA,Perini E,Rosa MB,et al.Medication errors and drugdispensing systems in a hospital pharmacy[J].Clinics,2005,60(4):325-332
3 Huff ED.Systems analysis of adverse drug events[J].JAMA,1995,274(1):35-43
4张小宁,王晓民.医疗差错中的人为因素与柔性工程应对策略[J].医学与哲学(A),2017,38(5):82-84
5 Wickens CD,Hollands JG.Engineering psychology and human performance[M].New York:Harper-Collins,1992:121-123
6 Parker SH.Human Factors science:Brief History and Applications to Healthcare[J].Curr Probl Pediatr Adolesc Health Care,2015,45(12):390-394
7孙志强,史秀建,李欣欣,等.基于认知模型的人为差错分类方法[J].国防科技大学学报,2008,30(1):73-77,93
8吴小明,戴立操.基于信息理论的核电厂操纵员认知工作负荷研究.[J].价值工程,2015,34(22):161-164
9中国药学会医院专业委员会.推荐的四个药品管理标示[EB/OL].(2012-05-04)[2018-02-20]http://www.cpahp.org.cn/ccyyf/news/201205/1446.htm
10 Treisman A.Features and objects in visual processing[J].Scientific American,1986,225(5):114-125